- October 30, 2024
- Posted by: Thomas Anderson
- Categories:
The American Medical Association (AMA) CPT Editorial Panel has decided to eliminate the requirement for patients to transmit data for at least 16 days to qualify for remote physiologic monitoring (RPM) billing, starting in January 2026, according to a publicly available document.
Previously, patients needed to use a device and transmit data for at least 16 days within a 30-day period for providers to bill RPM codes, which cover remote patient monitoring services. This decision comes amid concerns from the Peterson Health Technology Institute, which recently questioned RPM’s effectiveness in managing hypertension. Additionally, a September report from the Department of Health and Human Services Office of Inspector General (HHS OIG) flagged potential billing fraud in RPM, with one representative stating taxpayers are unaware of what they are funding.
The AMA CPT Editorial Panel, which met in Washington, D.C., from September 25 to 28, reviewed proposed changes to RPM and remote therapeutic monitoring (RTM) codes. The panel voted to remove the 16-day data transmission requirement, which has long frustrated providers. The high data submission threshold often prevented providers from being reimbursed for RPM services, as it was challenging to ensure patients would consistently use connected devices, such as weight scales or blood pressure cuffs, on alternate days.
Providers have argued that data from fewer than 16 days per month could be adequate for patient care, with more frequent reporting sometimes being unnecessary or even counterproductive. In the proposed 2024 Medicare Physician Fee Schedule (MPFS), the Centers for Medicare & Medicaid Services (CMS) incorrectly stated that certain RPM and RTM codes required 16 days of data collection.
The HHS OIG recently raised concerns over whether RPM codes were being billed alongside other related codes as intended. The report noted that about 43% of RPM patients did not receive the full set of monitoring components, leading to questions about proper usage of RPM services. CMS’s final 2024 MPFS clarified that specific treatment management CPT codes, including 99457, 99458, 98980, and 98981, are billed based on monthly provider time spent rather than on a 16-day data minimum.
Although RPM billing fraud remains a concern, some RPM experts argue that the 16-day data threshold isn’t a valid metric for identifying misuse. With the removal of the 16-day rule, it may become easier for OIG and other oversight bodies to assess potential misuse of RPM codes.
Numerous companies and engagement tools now support patient compliance with at-home devices. However, for providers not partnered with an RPM service, engagement falls on internal staff or the provider, making consistent data submission challenging.
The AMA’s Resource-Based Relative Value Scale Update Committee (RUC) is set to review pricing for these codes in January 2025. Coding experts have previously suggested that reimbursement for data submitted less frequently than the previous 16-day threshold might be lower than current rates.